Практика Shadowing: A pediatric cerebrovascular approach: techniques and challenges - Изучайте разговорный английский с YouTube

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practice is unique in the fact that I do about 90 percent,

85 percent of what I do is all children.

children with vascular malformations, both of the brain and the neck, maxillofacial areas.

We receive them from newborn actually to 19, 18 years of age.

We do of course also adults with vascular malformations,

but as things are evolving and you can see how fantastic this course is and the tremendous progress that has exist.

So children are not small adults and that has happened throughout medicine.

There was the general doctor first,

then became pediatricians, which was obviously that required different things.

So within the vascular lesions of the human body,

there's a certain amount of diseases that occur in children primarily,

and that affect children sometimes exclusively.

So, based on my practice,

I have dedicated myself to improve the treatment in those children,

decrease the radiation, decrease the time of the procedure,

being very meticulous with the technique, very meticulous with fluids.

For small children that are in severe heart problems with brain problems,

if you use the same techniques in adults,

you actually could have a lot of harm.

So there are dedicated, specific problems that occur in children.

There are specific, dedicated challenges,

technical, medical, physiological, that are specific for children.

And there's even difference between children and newborns.

We have newborns that are born in severe heart failure with a disease called vein of gallant malformation

that even treated is lethal within the first year of life.

So those children require techniques,

for example, we develop techniques to go through the umbilical artery.

So we can actually place a cathode from the umbilical artery to enter the body,

to then navigate into the brain.

In this pediatric population, the diseases are rare,

so it's very hard to do really trials.

We're more involved in developing devices,

actually because coming from children,

they can be translated towards adults.

We also have a lot of patients,

or practices, patients of rare diseases,

such as vascular malformation of the maxillofacial area.

very difficult to treat.

So we have developed techniques like direct percutaneous puncture.

Instead of going from the femoral artery and trying to catheterize them,

it's to actually use 3D angiography or the eye guide

or the different types of technologies that have been developed for adults

and try to use them to place catheters or needles directly into the malformation.

And that has changed the whole ballgame.

We also involve trying to develop things which are called sclerotherapy.

Sclerotherapy is a technique in which you inject something that will damage the endothelium.

And then the healing of that scarring,

that will produce scarring, will actually sclerose or thrombose or close and scar those vascular malformations that they cannot feel.

And that includes venous malformation.

That includes lymphatic malformations.

That includes arteriovenous malformation.

And we're using biological substances such as chemotherapeutic agents, bleomycin for example.

And they've made a tremendous change in the outcome of this patient.

Actually, we're trying to use more and more ultrasound to guide ourselves to do these procedures.

Also, within the medical industry of x-rays,

we're forcing the manufacturers to create things like last image hold.

And then with that last image hold,

will, for example, collimate, try to center memories so that we don't have to radiate these children.

Mothers come to me and ask me that,

will my child have a stroke while you're doing this horrible malformation?

They ask me how much radiation are they gonna get?

Or the anesthesia?

Well, there is a potential role for endovascular radiosurgery.

I worked like 15, 20 years ago to try to treat vascular malformations that way.

But radiation is a difficult thing to control.

It's a difficult thing to prove,

a difficult thing to get approved through a regulatory pathway like the Food and Drug Administration and so on.

And dangerous for everyone, including you as an operator.

Everything is dangerous if it's improperly used.

You know, if you have a genie and you let the genie out of the box and there's no control,

it can be very, very dangerous.

So I would say that radiation has a potential,

but it is not something that is around the corner.

The tools that we have today are pretty much adaptation of adults to children.

So we're still at the beginning.

We're very much interested in developing tools that are designed for newborns and for children,

which today do not exist.

So we take a catheter that is a meter and a half,

because it's the only catheter that we have.

The technology exists, but the market is so small

that industry is not very interested in developing high technology for a very small market.

And this is not simply the question of smaller arteries.

It's a whole question of a different anatomy that you're dealing with.

It's a different anatomy.

It's a different technology necessary for the stiffness, for example.

You know, the blood vessels in children are more fragile in a sense.

But on the other hand, they're more elastic.

So they have their own specific problems,

both technically as well as physiological.

One of the biggest questions that we have is if we take a device,

for example a stent, that is developed for adults which have stopped growing and we put them in small children,

what would happen to those vessels as we increase in size?

And therefore, personally, we have a lot of skepticism of using stents unless we are really forced.

And the other side of the coin is we're going to press

and push industry to develop bioactive or biodegradable devices so that

if I put a stent in a little child and that stent will then be reabsorbed,

it will permit then the normal physiologic growth.

Biodegradable, bioabsorbable, biocompatible.

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It's one of the great, great, great potential expansion.

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If we can develop it for children,

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it can then be transferred to adults.

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What is interesting is that we've done very small devices based on trying to do it for pediatrics,

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and those have translated to go to the adult,

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which permits you to go to more distal circulation.

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I think that's very valuable for the training of physicians.

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You know, when I started,

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it was see one, do one,

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teach one, that no longer applies.

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We're not, it's just so much better to train,

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and I'm very involved in the training of physicians,

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training physicians in a in vitro model.

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You know, get all, I mean,

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you actually today, the reproduction is, Dr. Moret, so fantastic.

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You know, it's literally like the real thing.

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But then you get the physician to learn.

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You get the physician to train,

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you get the physician to try,

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you get the physician to make the mistake in a model.

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By the time you transfer that to the real patient,

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you have a much better trained physician.

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And I think industry is now more and more turning to these models.

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And the regulatory agencies are saying,

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wait a second, you not only have to go and train in a model first.

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You know, it used to be sometimes an animal.

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Then, you know, as you know,

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there's a lot of movement against training in animals.

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So these things have replaced a lot of the training.

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The regulatory agencies will force us to train physicians in this type of models that are now readily available.

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3D printing can make exactly the same aneurysm immediately, right away.

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And not only that, I can make 20 of those,

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or 50, or 100 to train physicians.

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So that I do believe that following that comes the proctoring.

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In other words, now you're going to go,

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this individual who's trained in the model is going to go do humans.

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So when you go humans,

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you go with somebody experience,

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the fracture you, I think that is absolutely the way to go.

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